Medicare Provides Greater Access to Home Care

Qualifications for home-based PT and OT now include “maintenance care.”


A few years ago, many people receiving physical therapy or other services at home had these services cut off. Why? Because it determined these sessions weren’t likely to improve your condition. If that was the determination, Medicare would deny coverage.

“Agencies were denied reimbursement for care if patients didn’t show improvement,” says Diane Omdahl, a registered nurse who founded 65 Incorporated, a service to help those on Medicare understand their benefits. This made home health agencies “gun shy” about accepting clients.

“Improvement” was once part of the criteria Medicare used to justify continued payments for home care services. Then in 2012, Medicare recipients and disease advocates took the issue to court. Patients argued that they need skilled maintenance care, and that Medicare is obligated to pay for it. The federal judge agreed. In January 2013, the “improvement standard” was removed from Medicare’s Benefit Policy Manual.

Denials Continue

Even though the improvement standard was overturned, the Center for Medicare Advocacy (CMA) still hears from Medicare recipients who are being denied coverage on that basis. Health care professionals may not know about or understand the new guidelines because they have spent decades relying on the improvement standard – and changing that “will involve turning the battleship around,” Omdahl says.

It’s important to remember that Medicare has several other requirements for payment that are unchanged by the ruling. For example:

  • A physician must prescribe home care.
  • A patient must be homebound. Brief, intermittent trips outside the house are OK, but Medicare regulations don’t clearly define “homebound.”
  • The care must be skilled. Medicare will pay for a nurse or therapist, but not for the kind of general care provided by a home health aide.
  • The care must be necessary and reasonable.

Now that the improvement standard is gone, regulators might be even stricter in evaluating claims against the remaining criteria, Omdahl warns. CMA offers free information packets to help patients and caregivers understand their rights, and learn how to appeal improvement standard-based denials.  

Know Your Options

Patients who were denied Medicare home health benefits under the improvement standard after the lawsuit was filed have several options, says Letha McDowell, an elder care attorney who practices in Virginia and North Carolina. Her suggestions range from simple to more involved:

  • Contact the prescribing doctor. At the very least, the physician’s order will help establish the need for home care.
  • Contact the home health agency. The agency may re-file a denied claim. “If they’re going to get reimbursed, it’s advantageous for them to provide the care,” says McDowell.
  • Contact a third party for help. Help might come from an elder care law firm, an advocacy organization or patient care organization.

If a doctor prescribes skilled home care, patients and their caregivers should ask the physician to tell them specifically what skilled service is needed, recommends Bill Dombi, vice president for law at the National Association for Home Care and Hospice in Washington, D.C. For example, teaching a patient exercises to avoid contractures of the hand may require skilled therapy services. By comparison, a patient may not need skilled care to learn simple exercises that promote mobility and general good health.

It’s likely that patients with chronic conditions like arthritis will only need skilled home care intermittently, says Omdahl. After home care is prescribed, a nurse or physical therapist will conduct a detailed assessment of the patient’s health and create a personalized care plan. Depending on the person’s situation, that plan might call for skilled care – such as a registered nurse to teach how to administer pain medication, or a physical therapist to help with an assistive device such as a cane or brace. Skilled nursing can even include non-drug approaches to pain management, such as music or guided imagery, says Karen Carnes, a registered nurse with Interim HealthCare, a home care group based in Sunrise, Fla.

In 2013, about 3.5 million Medicare recipients received home health care, at a cost of nearly $18 billion. (Private insurers are not required to adopt Medicare’s guidelines, but in practice they often do, notes Carnes.) Removing the improvement standard from Medicare’s policy has given patients greater access to home health care coverage. “People are not being cut off as quickly,” says McDowell.

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